19 year old female with shortness of breath from the past 10 days



CHIEF COMPLAINT - 

19-YEAR-OLD FEMALE PRESENTS WITH  SHORTNESS OF BREATH FROM THE PAST 10 DAYS. 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 

6 months ago, she experienced a heavier flow in menstrual bleeding, which has worsened in the last 3 months - where her cycles occur every 30 days and she bleeds for 5 days during which she has to use 10 -15 pads a day for the first 2 days. 

She presented to the OB&G for the same and she was then referred to General Medicine.
 
From the past 10 days, the patient complains of shortness of breath on walking 4-5 steps, speaking, and even eating food associated with fatigue weakness palpitation, and sweating. 

She complains of sudden breathlessness while in sleep that subsides when she takes a stroll in the greens for around 5 minutes - this has happened intermittently, and has occurred more in the last week. She also complains of slight difficulty in breathing while lying down-on being asked she says that it does not bother her so much. 

On the day of admission - she complains of a severe episode of shortness of breath when she was packing to get to the hospital, which subsided when the ASHA worker near their apartment made her sleep to the side, opened the windows, and made her smell camphor. 
PAST HISTORY  

Patient was born to parents of a non-consanguineous marriage, through an FTNVD(Full Term Normal Vaginal Delivery) with a weight of 3.5 kg, was breastfed for 4 years, and immunized as per universal immunization schedule. 

When the patient was 
  • 5 YEARS OLD - she came to the hospital with complaints of shortness of breath on walking, was transfused with 1 UNIT blood 
  • 10 YEARS OLD - SOB leading to difficulty in walking /playing; she was diagnosed with hypothyroidism and was started on 25ug of THYRONOM- dose was gradually increased to 75 ug, then to 150 ug and later decreased to 100ug over a period of time. 
  • 12 YEARS OLD - she was brought to the hospital because she was not growing in height and was obese. She was admitted to a hospital where bone marrow aspiration was done. The result is unknown as the documentation is lost. the patient was given Calcium, Iron, and Multivitamin Supplements which she took for two months, attained menopause 6 months later. 

DRUG HISTORY 
  1. Thyronorm
  2. Calcium, Iron, and Multivitamin supplements 
PERSONAL HISTORY 
  • Diet- Mixed- prefers vegetarian food 
  • Appetite- Normal 
  • Sleep reduced from the past 10 days 
  • Bladder and bowel movements -Normal 
  • She has lost 5kgs of weight in the last month 
  • no history of fever, blood in stools,hematemesis

FAMILY HISTORY - 

  • Grandmother H/O thyroid issue 
  • No similar complaint in sibling who is 1.5 years older than her 

MENSTRUAL HISTORY 

  • Attained menarche at 14 years of age 
  • 30/5 cycles
  • Pain -present
  • Clots - absent 
  • Uses 10-15 pads in the first 2 days of her period and then uses 2-3 pads/day in the remaining days. 

GENERAL EXAMINATION - 
  • Patient is conscious coherent and cooperative and oriented to time, place, and person 
  • Pallor - Present 
  • Absence of icterus, cyanosis, lymphadenopathy, pedal edema, koilonychia
  • BP- 90/60mmog Hg 
  • RR-24 cycles per minute 
  • PR- 80 breaths per minute 
  • diffuse enlargement of the thyroid gland 
  • JVP- raised 

  • Knuckles -Hyperpigmented. 

  • purpura- mild  


RESPIRATORY SYSTEM EXAMINATION - 
  • Trachea - central in position 
  • BAE- present 
  • NVBS -heard 

CARDIOVASCULAR SYSTEM EXAMINATION - 
  • S1, S2 heard 
  • No murmurs 
  • Carotid bruit - present 
  • Hyperdynamic apex

PER ABDOMEN EXAMINATION - 
  • Non-tender
  • Grade 3 Splenomegaly (Spleen extended up to the umbilicus )
  • Liver span - Dullness on percussion from 6th ICS  to 3 cm from the right coastal margin 
  • bowel sounds heard 

CNS EXAMINATION 
  • Higher mental functions - normal 
  • No focal neurological deposits 

INVESTIGATIONS - DAY 1 -7/7/2021

1. Hemogram : (Morning
  • HB- 4.5 gm/dl
  • TC -2100 cells/cmm
  • neutrophils -35 percent
  • Lymphocytes -60 percent
  • eosinophils-1 percent
  • monocytes -4 percent
  • basophils -0 percent
  • PCV- 13.6 volume percent
  • MCV- 129.5 fl
  • MCH-42.9  pg
  • MCHC- 42.9 percent 
  • RBC count -1.05  millions /cumm
  • Platelet count -80,000 /cumm
2.Thyroid Function test - 
  • TSH - 61.33  micro lu/ml
  • T3-82.84 ng/m
  • T4-9.52 micro g/dl
3. Random Blood Sugar- 125 mg/dl

4.PROTHROMBIN TIME -14 seconds
  • APTT-30 seconds
  • INR-1.0
5. LDH-  801 IU/L
6. LFT ;
  • Total Bilirubin - 1.47 mg/dl
  • Direct Bilirubin- 0.66mg/dl
  • SGOT-58 IU/L
  • SGPT -22IU/L
  • ALP-85 IU/L
  • TP-6.4 gm/dl
  • Albumin -3.9 gm/dl
  • A/G  1.6

7. ECG 



8..CHEST X RAY-

9.ULTRASOUND REPORT - 





REVIEW OF USG - AS OF 8/7/2021





10.COLOUR DOPPLER- 2D ECHO



11. PERIPHERAL BLOOD SMEAR - 7/7/21




Findings - 
RBC- Anisopoikilocytosis with microcytes, macrocytes, and teardrop cells 
WBC - Reduced on smear with lymphocytosis 
Platelet Count - reduced on smear 
Pancytopenia


12. HEMOGRAM - 7/7/21(EVENING ) 
  • HB- 4.1 gm/dl
  • TC -1800cells/cmm
  • neutrophils -25 percent
  • Lymphocytes -70 percent
  • eosinophils-1 percent
  • monocytes -4 percent
  • basophils -0 percent
  • MCV- 129.0 fl
  • MCH-44 pg
  • MCHC- 34.2 percent 
  • RBC count -0.93  millions /cumm
  • Platelet count -36000/cumm
  • RDW-CV-23.3
  • RDW-SD-94.9
13. Reticulocyte count - 0.7 percent 


14. SARS-COV-2 Qualitative PCR (8/7/2021)






15. AHG(COOMBS TEST ) (8/7/2021)



16. BONE MARROW ASPIRATION AND PERIPHERAL BLOOD SMEAR  - 4/4/14 

The patient had slides of the bone marrow aspiration and peripheral Smear which was done  when she was 12 years old, these were reviewed, 











PROVISIONAL DIAGNOSIS - 
Anemia under Evaluation 
?Myelodysplastic Syndrome
?Aplastic anemia



TREATMENT PLAN - 

Bone marrow Aspiration 

TREATMENT 7/7/21 -4:00 PM 
  1. Tab . THYRONORM 150 mg OD
  2. Tab. LASIX 40mg 1--0--1


TREATMENT  - 8/7/21
  1. Tab . THYRONORM 150 mg OD
  2. Tab. LASIX 40mg 1--0--1
  3. Tab .OROFER XT  BD 1--0--1
TREATMENT -11/7/2021
  1. Tab . THYRONORM 150 mg OD
  2. Tab. LASIX 20mg 1--0--1
  3. Tab.Regestrone 10mg 1-1-1
  4. Tab. PAUSE-MF 1-1-1
  5. Inj.VITCOFOL IM/BD 1ml(500mg)
TREATMENT - 12/7/21
  1. Tab . THYRONORM 150 mg OD
  2. Tab. LASIX 20mg 1--0--1
  3. Tab.Regestrone 10mg 1-1-1
  4. Inj.VITCOFOL IM/BD 1ml(500mg)

DISCHARGE SUMMARY 


Diagnosis - 
PANCYTOPENIA UNDER EVALUATION (/VITAMIN B12 DEFICIENCY /?HYPERSPLENISM)
MODERATE SPLEENOMEGAY 
HYPOTHYROIDISM 
MENORRHAGIA 


ADVISE AT DISCHARGE 
  • TAB. THYRONORM 150MCG OD
  •  INJ. VITCOFOL (1ML = 500MCG) IM/BD FOR 5 DAYS F/B
  • INJ. VITCOFOL (1ML=500MCG) IM/OD ON ALTERNATE DAYS FOR 1 WEEK F/B
  • INJ. VITCOFOL (1ML=500MCG) OD ONCE IN A WEEK FOR 1 MONTH
  • TAB. REGESTRONE 10MG TID FOR 3 DAYS
  • F/B TAB. REGESTRONE 10MG BD FOR 5 DAYS
  • F/B TAB. REGESTRONE 10MG OD FOR 5 DAYS.
  • TAB. OROFER-XT OD FOR 1 MONTH.
  • Regular Excercise 
FOLLOW -UP 
REVIEW AFTER ONE WEEK TO THE OBGYOPD 

Case discussion : 

Q. What are the causes of splenomegaly and what reasons do you think are the most likely cause for splenomegaly in this patient? 

A. There are various causes of Splenomegaly including Liver cirrhosis, Splenic congestion, splenic sequestration, and acute or chronic infection cytopenias. 


In our patient the most likely cause is pancytopenia. 

Q. What is pancytopenia ? And what do we do to evaluate a case of pancytopenia ? 

"Pancytopenia is a hematologic condition characterized by a decrease in all three peripheral blood cell lines."


Evaluation in a case of pancytopenia involves a complete blood picture, peripheral blood smear, and bone marrow aspirate cytology. 

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